Healthcare Provider Details

I. General information

NPI: 1073816765
Provider Name (Legal Business Name): PETER BADUA PAC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/18/2010
Last Update Date: 12/18/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

53 CRONIN DR
SANTA CLARA CA
95051-6719
US

IV. Provider business mailing address

53 CRONIN DR
SANTA CLARA CA
95051-6719
US

V. Phone/Fax

Practice location:
  • Phone: 408-984-2455
  • Fax: 408-984-2456
Mailing address:
  • Phone: 408-984-2455
  • Fax: 408-984-2456

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code163WR0006X
TaxonomyRegistered Nurse First Assistant
License Number
License Number State

VIII. Authorized Official

Name: MR. CHARLES DAMON FRACH
Title or Position: OFFICE MANAGER
Credential: PHD
Phone: 408-984-2455